emergency department directors academy phase iii spring 2020 · dealing with problem performance...

Emergency Department Directors Academy Phase III Spring 2020 The Problem Provider DESCRIPTION The problem provider comes in many forms, among them: bad attitude, poor clinician, slow as molasses, too fast, and impaired. This presentation will focus on the development of early recognition and rapid response. Counseling methods, corrective actions, termination procedures will be described and practiced. OBJECTIVES

• Describe typical forms of the problem provider requiring counseling and remediation including impairment, harassment, inefficiency, behavioral issues, poor communication skills, knowledge gaps, etc.

• Define the components of a counseling session including communication style, content, setting goals, creating buy-in, and documentation.

• Develop a plan for counseling and remediation and determine how success will be measured. • Role play a termination procedure. • Provide references after termination.

2/3/2020, 1:00 PM - 3:00 PM; 3:15 PM - 5:15 PM FACULTY: Randy L. Pilgrim, MD, FACEP DISCLOSURE: (+) No significant financial relationships to disclose

The Problem Provider

Randy Pilgrim, MD, FACEP

ACEP EDDA Phase III

2

Objectives

1. Self Assessment

2. Role Play

3. Skills Lab

4. Difficult Issues

5. Separation

6. Round-table discussions

3

Medical Director Roles(Just a few)

• Clinician• Leader• Manager• Communicator• Educator• Problem Solver • Role Model

• Team-builder• Coach• Counselor

• RELATIONSHIPS

4

Common IssuesClinical• Knowledge• Skills• Proficiency• Cognitive Issues• Productivity• Documentation

Non Clinical• Efficiency• Teamwork • Communication• Peer Issues • Attitude / emotional issues• Impairment• Inappropriate language / behavior• Sexual harassment• Personal habits

Other• Rejects targets and goals • Doesn’t participate• Debates everything; never satisfied• Family or personal issues• Repetitive problems

5Individual Performance

Team Performance

Organizational Performance

6

Doing this well can mean:

• Excellent medical care• Meeting targets• Happier workplace• Great relationships• Pride, satisfaction• Productive partnerships• Sustainable excellence

7

Mission, Vision, Values

Effective Relationships

EliminateUndesirable

ResultsReinforceDesirableResults

Getting this “right”

GreatTeams

8

Is this a “Problem”?If it’s a problem for:

– The team– The leadership– A significant stakeholder

If it’s not consistent with:– Mission and Vision– Guiding Principles– Acceptable behavior or performance standards– Progress toward targets and goals

Then, it’s a problem.

9

Dealing with Problem Performance

Three options:

Prevent it.

Remove it.

Change it.

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What’s So Difficult?

• Not trained• Unsure of role or

responsibilities• Intimidated• Fear negative

reactions• Relationship risk

• Reminds us of our own shortfalls

• Uncomfortable telling others how to practice or behave

• Feel inadequate• Physician shortage

11

Implications

Why is this critical for success?

The Problem

• The Issue• The Physician• The Team• You

Not Dealing with the Problem

• The Issue• The Physician• The Team• You

12

Reasons Why People Fail

• Unclear roles and responsibilities

• Unclear objectives

• Lack of basic knowledge and skills

• Unsure how success is measured

• Unsure of current results

• No Feedback, Coaching, or Counseling

13

Why Employees Really LeaveBy analyzing data from close to 20,000 interviews conducted by

the Saratoga Institute, Branham uncovered reasons for employee turnover:

1. Job or workplace was not as expected.

2. Mismatch between job and person.

3. Too little coaching and feedback.

4. Too few growth and advancement opportunities.

5. Feeling devalued and unrecognized.

6. Stress from overwork and work-life imbalance.

7. Loss of trust and confidence in senior leaders.

Why Employees Really Leave

14

Too Little

Too Much

Misses the

Point

Errant Approach

•Lack of clarity

•Poor technique or skills

•Vilify the source

Dysfunctional Approaches to Problem Performance

•Indirect•Apologetic approach•Minimize the problem•Nothing (avoidance)

•“Dumping”•Unnecessary threats•Premature Approach•Address too many issues

•Tangential approach

•Over-emphasize strengths

16

Objectives

1. Self Assessment

2. Role Play

3. Skills Lab

4. Difficult Issues

5. Separation

6. Round-table discussions

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“Hot Spots”

• Impairment

• Sexual Harassment

• Teamwork

• Peer issues

• Difficult personalities

• Clinical issues

“Working up” a Problem

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Identify Qualify Intervene Follow up

Problem Behavior and Performance

* *

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• Dr. A is “slow”

• TLOS is 45 minutes longer than average

• 3 new complaints

Issue:

Approach: The Medical Director:• demonstrates interest• listens• asks for time to assess• sets time frame for action plan

The Problem

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q Overly organized and single-track

q Often adds orders

q On the phone for long periods with attendings

q Thorough workups

q Waits for “whole team”

Knowledge

Assessment:

Skill Clinical ExpertiseBehavior Style

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The “Work-up”

1. Chief Complaint2. History 3. Exam / Labs 4. Decision-making5. Treatment 6. Disposition7. Communication8. Follow-up

1. Identification2. Understanding3. Investigation4. Decision making5. Intervention6. Disposition7. Communication8. Follow-up

PATIENTS MANAGEMENT

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• Clinical vs. non-clinical • Facts or perceptions (or both)• Acceptable vs. unacceptable

• Desirable behavior • Desirable outcome

“The Gap”

“Doorway Disposition”

Be Clear:

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1 2 3 4 5

No action.

Inform & support.

Counsel,

Advise,

Educate,

Trend

Remediation or

Education

Prompt

TerminationImmediate

Termination

Disposition

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Legitimate concern;

Opportunity for improvement

Concern not validated or not significant

Counsel,

Advise,

Educate,

Trend

No action.

Inform & support.

2

1Disposition

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Serious concern

Questionable skills or knowledge base for facility’s demands

Remediation or

Education

3

Disposition

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• Gross negligence• Significant professional misconduct • Acutely impaired physician

• Repeated or significant problem(s)• Violates “remediation” provisions • Refuses to cooperate with reasonable

remediation plan• Consistent threat to safety of patients, family,

or staff• Substantially disruptive to team or

environment

Immediate Termination

Prompt

Termination

4

5

Disposition

28

Remediation or

Education

Counsel, Advise, Educate,

Trend

No action. Inform & support.

Immediate Termination

Prompt Termination

1 2 3 4 5

Disposition

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Gather information promptly

Clarify & qualify the concern

Appropriate discussion withPhysician. Decision.

Physician concern

3Remediation or

Education

2Counsel, Advise, Educate, Trend.

1No action.

Support & build relationship.

5Immediate

Termination

4Prompt

Termination

Decision Making

Role Play

V

Intervention

V

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Identify Qualify Intervene Follow up

Problem Behavior and Performance

*

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Feedback

Coaching

Counseling

Information

Encouraging CriticalAffirming FocusingConstructive Keeps “moving”

Broader Interventional Deeper Things “stop”Wider

Style

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Dr. A Dr. B Dr. C Dr. D Dr. E

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• Frequently, entirely absent• Great coaching tool

• Scheduled and “on the fly”• Verbal and written • Positive and constructively critical

• Reinforces mission, targets, and team work• Sets up evaluation• Prevents counseling and interventions

Feedback

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Definition Expectation Decision-Making Separation

GOAL:

Awareness Remediation Specific Performance

Resignation or

Termination

Counseling Continuum

Where you

need to be.

GAPWhere

you are.

Path


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• Trained to be logical• Trained to be critical• Respect “evidence”• Prefer fact-based arguments• Value autonomy• Make quick judgments• Little tolerance for “politics”• Tend to believe that facts or logic are more

important than perceptions

Physician Motivation

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• “When I (see, hear)_____________________”• “I become concerned about_______________”, or

“I feel______________________________”

• “What I’d like instead is:__________________”• “So that ______________________________”

A well-constructed, well deliveredI - statement

Technique

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Where are you?

Where do you

need to be?GAP

1. DEFINITION 2. EXPECTATION

AWARENESS REMEDIATION


GOAL: GOAL:

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(What)(By when)

(If not: ____)

GOAL:GOAL:

3. DECISION-MAKING 4. SEPARATION

SPECIFIC PERFORMANCE

RESIGNATION OR TERMINATION


(When)

(How)

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Feedback

Definition Expectation Decision-Making

Separation

GOAL:


Resignation or

Termination

Coaching Counseling

Special Situations and

Case Studies

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Speed / Efficiency / Productivity

Common dysfunctional patterns:• Too slow• Too fast• Poor organization (scattered, order-adder, etc.)

Approaches:• Identify core issues• Identify how behavior affects stakeholders.• Identify competing demands; prioritize

• e.g. afraid of complaints => excessive time with patients• e.g. driven to be thorough => time-consuming workups

• Affirm positive behaviors & results• Agree on objective targets (ALOS at or below 3 hours in 30 days. . .)• Agree on subjective targets (nurse feedback positive; no complaints)• Practical suggestions

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Sample Suggestions:Efficiency & Productivity

1. Stay focused.

2. Anticipate phone calls to staff and residents. Put out calls early.

3. Admit patients who obviously need to be admitted.

4. Order all necessary tests at one time.5. Focus on disposition and long-term plan.

6. Use down time effectively.

7. (etc. . .)

Source: ACEP; Todd L. Beel MD FACEP

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Sexual Harassment

• Any unwelcome or unwanted advance, request for favors, or physical contact

• If submission to or rejection affects decisions (hiring, retention, promotion)

• Creates intimidating or hostile work environment

• A violation of the law

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• Most common form of illegal harassment• Lowers morale and productivity• Violates policy• Conduct outside of work is relevant• Illegal

• Two Types– Quid Pro Quo (“this for that”)– Hostile work environment

Sexual Harassment

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Prevention• Ensure that this is covered in orientation• Reinforce annually (Corporate Compliance affirmation, etc.)• Address issues before you receive a formal complaint

Intervention• Address promptly• Work-place continuum:

Subjective concern => Observed (objective) concern =>Voiced concern => formal complaint => law suit

• This usually doesn’t go away on its own• Be forthright (not casual)

Sexual Harassment

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Approach must address:

• The behavior – Commitment to stop (regardless of intention)

• The emotional impact – (feels afraid, intimidated)– Overt reassurance

• The workplace – (no retaliation)

Sexual Harassment

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• Corporate Counsel • Employee vs. Independent Contactor issues• What are the standards outlined in your group’s

orientation materials?• What are the Hospital policies & procedures?• Corporate Compliance considerations

Sexual HarassmentStrategies & Resources

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Which style?Feedback Coaching Counseling

Which phase?

Definition Expectation Decision-Making

Separation

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Impairment Common Presentations• Drugs, alcohol, psychiatric

Issues• Very common• Denial and enabling. . .• Suspicion vs. evidence vs. a workplace

problem

Strategies• Professional assistance • Involve family/peers/clergy• Use established recovery networks• Prepare for long-term• Very painful, but• Often satisfying and successful

56

Common Presentations• Drugs, alcohol, psychiatric

Issues• Very common• Denial and enabling. . .• Suspicion vs. evidence vs. a workplace

problem

Strategies• Professional assistance • Involve family/peers/clergy• Use established recovery networks• Prepare for long-term• Very painful, but• Often successful and satisfying

Impairment

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Definition:“Any physical, mental, or behavioral disorder that

interferes with the ability to engage safely in professional activities.” (AMA)

Action:• Intervene early and assertively

Resources:1. http://www.ama-assn.org/ama/pub/category/8528.html2. http://www.asam.org/ (American Society of Addiction Medicine)

Impairment

http://www.ama-assn.org/ama/pub/category/8528.html

http://www.asam.org/

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Peer IssuesCommon Presentations

Workplace issues– Tardiness – No-shows– Chart-selectors– Non-participant (committees, QA/QI)

Repeated scheduling issues– Inequity (cherry picker)– “Fair share”

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Prevention• Clear expectations up front• Develop rules by consensus• Declare rules if needed (benevolent dictator approach)

Treatment• Requires frequent low doses of corrective input• Don’t try to handle too indirectly

– Use I-statements and direct communication• Peer approach to enforcement

– Scheduling consequences– Financial consequences– Peer discussions

Peer IssuesStrategies and Resources

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Common Clinical Issues• Knowledge (Know it)

• Skills (Do it)

• Proficiency (Do it efficiently and well)• Cognitive• Technical

• Cognitive Issues:− Rules-based − Interpretive − Diagnostic / decision making

• Productivity

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Know the “standard”:• Evidence-based• Community standard• Consensus-based

Identify the deficit. Focus on specific implications.• Patient outcome• Medical staff issues• Medical legal concerns• Productivity (be specific)• Current vs. future issues

Often, it takes more than a chart review.• Physician may debate the issue or the standard.• Physician may resent “intrusion” into practice.• Documentation issues may surface.

Key Points: Clinical Issues

62

• Individualize action plans– Self-study, CME– Resources (written, web-based, etc.)– Shadowing – Mentorship

• Ongoing evaluation & follow-up– Continued review of performance– Clear expectations & time frames– Leave room for reasonable judgment– Advocate for good care without apology– Address documentation– Productivity: look for improvements in

Ø Perceptions (early)Ø Data (later)

Key Points: Clinical Issues

63

• Common issue: the “under-miner”

• (Possible failure to manage the buy-in process)

• Requires team approach (MD and RN)

• Usually need unified front– Opportunity to buy in– Reinforce positive behavior and results– Careful monitoring, followed by– Confrontation if necessary, then – Clear, crisp separation if ineffective

Teamwork

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Ingredients of Behavioral Change

Insight• The problem• The desired outcome

Desire & Commitment• Self-generated • Externally imposed

Skills

65

Ingredients of Behavioral Change

Environment• Allows and promotes desired behavior• Maintains the behavior

− Feedback − Positive reinforcement− Reasonable consequences

Ability to control negative behaviors• Emotional disorder• Impairment

Critical Conversations:Counseling Best Practices

V

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Delivery

Be sure the physician understands:

• The problem• The impact of the problem• What needs to change

• Possible consequences • what may happen if behavior does not meet expectations

• Strengths• Your support

• Affirmation of expected performance

The “GAP”

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Timing

• As soon as possible

• Day off is best (patient care not compromised) (shows it’s important to you)

• When you’re prepared

69

Setting

• Private• Quiet place

• In person (but don’t wait too long)• One-on-one (usually)

• Not at shift change • Not between patients

70

• Keep it simple • Prepare in writing• Practice initial delivery

• Focus on the physician (not you)• Sandwich method (?)

• Give examples

Techniques

71

• Offer techniques and tools• Acknowledge success• Explain how you will monitor progress

• Solicit a commitment to improve• Agree on future goals• Determine a time frame for follow-up

• Document (together?)

Techniques

72

• Be prepared for disagreement• Allow time and space for a response

• Empathize• Find ways to connect

– Past adversity– Relevant vignette

• Reinforce the definition of success• Reinforce expectations

Techniques

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Individualize

People are unique – Skills, knowledge, abilities, confidence, attitudes– Diverse backgrounds and perspectives– Trust develops differently

Individualize the plan– Understand motivators– Understand learning styles– Understand strengths and weaknesses

74

Anchors• Tell the truth• Integrity speaks softly, but very convincingly

• Refuse to personalize issues• Discuss issues, not people

• Defuse resistance with respectful persistence• Every disagreement is an opportunity

to improve a relationship

75

Key Messages

“I care about Excellent Medicine and Excellent Service.”

“Facts are important and Perceptions are important.”

“Fairness is important.”• Fair to physicians• Fair to others.

76

Do we have the same Mission, Vision, and values?• If not, is this changeable?• When?

Is he/she receptive?• To the concern?• To your leadership?

Appropriate awareness?

What is he/she responding to?

Listen

77

Counseling is not:• The only time to talk• An event• A panacea• Retribution

Pitfalls

78

• Address:– the physician– the stakeholders

• Affirm desirable behavior • Stay committed• Don’t miss timelines• Trend• Report• Document

Follow-Up

79

Priorities

• Mission, vision, and values• Patient safety and outcome• Patient experience• Healthy team• Healthy work environment• Meeting targets• Professional satisfaction• Personal satisfaction

Separation

V

81

Definition Expectation Decision-Making Separation

GOAL:


Resignation or

Termination


82

Timing:– Immediate?– Later (must clearly define)

Disposition:– Reassignment (e.g. lower acuity care)– Schedule modification(s)– Resignation– Termination

Separation Considerations

83

Contingencies:– Permanent?– Performance-based reconsideration?

• How measured?• When?

Rights & responsibilities:– Due process– Fair process– Contractual considerations

Separation Considerations

84

Things that sound like a Problem Provider – (but aren’t)

Task•Clarity•Task design•Guidelines•Accuracy of results

Institutional Context

•Economic context•Regulatory Issues•Legal framework•Constraints

Organization & Management

•Organization structure•Priorities•Financial constraints

Work Environment

•Staffing levels•Skills•Workload•Shift patterns•Support structure

Team•Leadership•Support•Communication•Consistency

Physician•Skills•Competence•Proficiency

Framework of Factors That

Affect Individual Performance

Patient•Acuity•Complexity•Communication•Social factors

85

• Medical-legal risk• Employer liability• Risk to the Department• Management risk• Leadership risk• Medical Staff

Bylaws/Rules • Hospital Privileges

• Employee rights• Contract Law Issues• Medical License

Issues• DEA Issues• Federal law• State law• Regulations

The Key:Know the issues

Manage accordinglyEngage appropriate assistance readily

Risk-related Considerations

Documentation

87

Gather information promptly

Clarify & qualify the concern

Appropriate discussion withPhysician. Decision.

Physician concern

3Remediation or

Education

2Counsel, Advise, Educate, Trend.

1No action.

Support & build relationship.

5Immediate

Termination

4Prompt

Termination

Decision Making

88

Purposes of Documentation• Professional

– Identifies strengths and opportunities for improvement

– Identify strategies for addressing issues– Communication

• Legal / Risk– Documents issues and events– Demonstrates process, communications, and

outcomes

89

• Balance the value of having a file with the risk of having one– Should I keep a record?– Where?– Who “owns” it?– Who has access?– Discoverable?

• Obtain legal advice– Discoverability issues– Labor law– Corporate Issues– Employee vs. Independent Contractor issues

Documentation

90

• Usually better to have something documented

• For significant or repeated issues, dictate together (at the end)

• For written forms:– Attach relevant information– Pre-complete “non-negotiables”– Write up action plans together

• Both sign the document

In General…

91

Problems with Documentation

• Failure to communicate standards• Failure to give timely feedback• Failure to give opportunity for correction

• Inconsistency in measuring performance• Failure to document• Failure to document correctly

92

Basic Rules

• Plan your writing• Review the finished product• Facts vs. opinions / assumptions• Avoid inflammatory statements• Remain factual and credible

Prevention

94

• Communicate a Vision• Build relationships• Hire well• Have a plan• Frequent feedback• Healthy evaluation process

Prevention

Prevention:Hiring Well

96

• Lack of knowledge• Lack of skills• Lack of resources• System / process barriers• (Stressors, burnout)• Different objectives• Different values

Why Do People Have Performance Issues?

97

HiringQualifications vs. Qualities

• Employer• College(s)• Honors• Education• Aptitude• Degree(s)• Credentials• Intelligence• Computer Skills

• Employees• Colleagues• Honor• Ethics• Attitude• Demeanor• Credibility• Integrity• Customer Skills

Source: Thom Mayer

98

Improve Collaboration“Owner’s Manual”

1. What motivates (or de-motivates) me?2. What promotes high levels of job satisfaction for me?3. What to I value?4. What do I believe to be true?5. What I need people to watch for and alert me to?6. What do I need from peers, colleagues and those

who work for me?7. What is my communication style?8. What are some of my favorite quotes/mottos?

Source: Diana Contino RN MBA

99

How Do I Hire the Right People?Service is how well something is done technically

Hospitality is how good something feels emotionally“Setting the table” the power of hospitality in restaurants, business and life –

HarperCollins 2006 Danny Meyer NY restaurateur

• Emotional Quotient higher than IQ• 49% is technical skill• 51% is emotional (hard to teach – but you can teach

managers to “spot” it)

• Qualities:• Natural warmth and optimism• Intelligence and curiosity• Work ethic• Empathy• Integrity and self-awareness

100

Behavioral Interview Questions

Used to:• Elicit real life experiences that demonstrate less

tangible traits (problem solving or flexibility)• Determine if the person can do the job • Determine if they have the characteristics to

make them successful

Tell me about• When you had to explain a difficult issue to someone.• A time when you had your greatest success in building team spirit.

RESOURCE

Bottom Line….

102

What really works. . .• Meaningful mission• Clear vision• Winning culture• Effective teams• Personal integrity

• Proper skills• Knowledge of risks and pitfalls

• Do your best, and• Tell the truth affirmatively, and with compassion.

103

InsightPersonality Assessments

• Birkman Method / Meyers-Briggs / DISC Personality Assessment

• 360 ° MD AssessmentSkills

Crucial Conversations (Kerry Patterson, et. al.) Crucial Confrontations (Kerry Patterson, et. al.)

Coach / CounselorGroup Process ExpertACEP EDDA II, III, (and IV)

Resources

104

Top 10 hints for success• Just do it• Do it soon• Do it in person• Consistently reference Mission and Vision• Be consistent• Be fair• Keep it simple• Be understanding, but firm• Always show respect (even in conflict)• Integrity is everything…

Thank you!